Healthcare Provider Details

I. General information

NPI: 1629248745
Provider Name (Legal Business Name): ELM OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2008
Last Update Date: 09/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7740 W NORTH AVE
ELMWOOD PARK IL
60707-4124
US

IV. Provider business mailing address

7740 W NORTH AVE
ELMWOOD PARK IL
60707-4124
US

V. Phone/Fax

Practice location:
  • Phone: 708-452-7200
  • Fax:
Mailing address:
  • Phone: 708-452-7200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH PANTON
Title or Position: MANAGER
Credential:
Phone: 708-452-7200